Paxson Barker, PhD, MS, RN

1. Work stress/strain, low job satisfaction, and intent to leave home health care nursing among Home Health Care Registered Nurses (HHC RNs) Paxson Barker, PhD, MS, RN

2. Purpose The purpose of this study was to explore the work stress/strain reported by HHC RNs that may influence job satisfaction and “intent to leave” their positions and/or profession.

3. Background • Home Health Care (HHC) services enable people to remain at home rather than use residential, long-term, or institutional-based nursing care. • By 2020, the greatest demand increase will be 109% for HHC nurses (HRSA, 2004) with a resultant 36% shortfall of HHC nurses (U.S. Department of Labor, 2007). • The most recent national average of turnover rates among HHC RNs is estimated to be 22% and an estimated 25-33% of HHC RNs report an “intent to leave” their current position. • Strategies to improve or remove the work environment factors that negatively influence the nurses may improve retention.

4. Statement of the Problem • Effort-Reward Imbalance (ERI) due to work stress/strain measured in other occupations results in low job satisfaction, which is recognized as an antecedent to Home Health Care (HHC) RNs “intent to leave” their current position and/or profession in the published literature. • HHC RNs, as caregivers, can experience disequilibrium between the amount of effort they invest in their care-giving in relation to the rewards and benefits they receive for those efforts. • If a lack of reciprocity occurs between the nurses’ efforts expended and the rewards received, then this imbalance can result in work strain/stress leading to low job satisfaction for the HHC RN.

5. Significance • This secondary analysis of HHC RNs responses is the first to apply the ERI model to calculate their ERI ratio/score from reported work stress/strain. • Acknowledging the specific issues reported by HHC RNs will help frame and develop the needed interventions required to improve the work environment of HHC nurses. • Research has demonstrated that latent conditions, such as inadequate staffing and the nurses’ work environment, are the primary sources of threats to patient safety and health care errors.

6. Study Aims 1. To identify categories of work stress/strain reported by the HHC RNs via the narratives contained within their 2006 questionnaire response. 2. To examine the association between the two Organization Of Work (OOW) components (effort, and reward) and “intent to leave” as well as examine the association between the two OOW components and job satisfaction, while controlling for personal characteristics. 3. To explore differences in the ERI scores between two sets of groups: (1) RITL respondents as compared to the NRITL respondents as well as (2) the respondents without a narrative as compared to the respondents with a narrative.

7. Literature Review • Recurring themes regarding sources of work strain in the published research studies include unreasonable administrative demands/expectations, excessive paperwork, low wages and benefits, lack of professional advancement, lack of autonomy,difficult work characteristics, lack of cohesive co-worker relationships, and emotional strain of the job (Ellenbecker, 2004; Navaie-Waliser et al., 2004; Flynn, 2005, Ellenbecker & Byleckie, 2005). • The literature review noted 17 published research studies exploring the HHC nurses’ job satisfaction and intent to leave but none of the studies included the ERI theory measuring work strain/stress among HHC nurses. • The ERI model was used to study burnout among 204 hospital nurses in Germany that noted nurses with reported effort reward imbalances had significantly higher emotional exhaustion and depersonalization scores measuring burnout. (Bakker et al., 2000).

8. ERI theory • The Effort Reward Imbalance (ERI) theory is a psychosocial model that incorporates external and internal components of work characteristics to assess levels of job strain/stress associated with job satisfaction. • The model assumes that work contracts are not always balanced in reciprocity of rewards for the efforts requested. • This imbalanced reciprocity of “high costs” and “low gains” results in work strain/stress that may impair successful self-regulation and this sustained strain/stress may result in an “intent to leave” among nurses

9. Study Narratives Study Narratives ANTECEDENTS Burnout ATTRIBUTES Negative organizational traits Inadequate financial compensation Co-worker support Exhaustion Work stress Fatigue Overwhelming paperwork Supervisor support COPSOC Items 1,5,6,8*,9*,11*,12*,13*,14,15,17*,18*,19*,20,21*,23*,25*,26*,28*,29*, 31*,32,33*,35,38*,39*, 40,43*,44* Personal Characteristics age race gender education yrs in HHC yrs with HHC employer HIGH/LOW ERI SCORE Job stress/strain ERI Items 2,3,4*,9*,11*,12*,13*, 17*,18*,19*,22*,23*,24,25*,27,28*,31*,34*,36*,37,38*,39*,45* Parent Questionnaire one OOW item JOB SATISFACTION JCQ Items 8,*9*,11*,13*,22*,28*, 29*,33*,36* FOCUS GROUP Items 4*,7,10,16,21*,26*,30, 31*,42,43*,44*,45*,46, 47,48,49 INTENT TO LEAVE Study Narratives REPORTED NOT REPORTED *Overlap of item sources Conceptual Framework

10. Aim 1 Results Top 6 issues reported in narratives: 1. negative organizational traits 69.4% (n=143) 2. work stress 63.6% (n=131) 3. love homecare 50.0% (n=103) 4. overwhelming paperwork 43.7% (n= 90) 5. inadequate financial compensation 42.7% (n= 88) 6. nurse attrition 40.3% (n= 83) 27.2% of eligible 206 sample specifically stated that they had left or were leaving homecare work

11. Aim 2 Results Logistic Regression final model for respondents with (206)and without narratives (572) for job satisfaction (n=772) * Significant p<.05

12. Aim 3 Results Proportion of high and low ERI scores by narrative group, respondents with narratives (206) and respondents without narratives (572). a Low ERI score (.01 – 1.00) b High ERI score (1.01 – 4. c Overcommittment scale included in the ERI scores

13. Aim 3 Results cont.’ Mean scores of ERI and OCERI scores with t test results for respondents with and without narratives. * statistically significant p <.05

14. Conclusions • The qualitative results were consistent and supported by published literature on HHC nurses and their work environment. • 27.2% (56) of respondents with narratives reported intent to leave. • 30.4% (17) of those 56 respondents with narratives specifically stated that they loved homecare. • Negative organizational traits (69.4%)was the most frequently reported issue among the respondents with narratives. • Work stress (63.6%) was the next most frequently reported and is also supported by the literature. • Respondents with and without narratives (n=778) The effort scale (subscales of exhaustion and cognitive stress) and reward scale (subscales of autonomy and rewards) were statistically significant for job satisfaction • 43.2% of the 206 HHC RNs with narratives reported elevated ERI scores • 35.0% of the 572 HHC RNs without narratives reported elevated ERI scores • The surprising result was that the group without narratives reporting elevated ERI scores, only 18.5% (n= 37) of this group (n=200) reported low job satisfaction despite the evidence of elevated work stress/strain • 65% (n=372) respondents without narratives reported no/low effort-reward imbalance and 97.8% reported experiencing good job satisfaction.

15. Implications for Policy • A place to begin is to establish federal standards for HHC nurses’ work environment including but not limited to work hours, physical hazards, overtime (paid and unpaid), workload, and safety so that all nurses are protected regardless of geographic location or employer. • The OASIS paperwork, (federal documentation requirements), and being grossly underpaid (federal reimbursement issue) are issues resulting in unpaid overtime for HHC RNs. The need for HHC RNs to use their uncompensated private family time to conduct business for their HHC agencies is an unreasonable expectation of employers and the federal government. • CMS reimbursement for patient services should be based on total hours worked including travel time to provide care versus only face time with patients. • The reported level of elevated effort-reward imbalance increases the responsibility and burden of management to identify the sources of job stress/strain in the work environment for their employees and intervene appropriately. • Policy makers need better data to improve the reimbursement of homecare nursing.

16. Implications for Practice • HHC agencies must balance their number of admissions to the amount of resources available to provide safe, quality care to the clients they serve. • The voices of these HHC RNs provides key information for the development of interventions that reduce and/or eliminate these work environment hazards. • Employers must address and resolve work hazards including unsupportive employer behavior, work stress, and unreasonable/excessive hours worked by HHC RNs to improve the retention of these highly qualified nurses. • Almost 50% of the 794 HHC RNs responding to this study reported elevated effort reward imbalances with 27% having left or planning to leave homecare. These results should capture the attention and response of decision-makers. • The employer can resolve many of the issues through improved “organization of work” policies.

17. Implications for Research • Quantitative analysis alone does not provide comprehensive results and interpretation of the HHC RNs lived experience and requires the inclusion of qualitative analysis to capture relevant data. • Additional research using the ERI model is indicated to assess levels of work strain/stress among HHC RNs. • Hazards in the HHC RNs workplace persist despite published literature identifying these hazards due to a disconnect between research and practice. This disconnect indicates that improved dissemination of research results to federal policy and decision makers is needed. • The nurse’s voice must be respected, heard, and responded to appropriately for resolution of practice errors and problems in the health care delivery system of homecare. • Qualitative research is required with quantitative methods to achieve an in-depth understanding of the phenomena of workplace issues among HHC RNs. • Homecare employers need research findings to identify and implement needed changes in homecare documentation and compensation to retain nurses.

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